Week 5 / Test 2 - Newborn

NSW - Meds - Nursing Actions

- Assess IV site frequently - Check for med incompatibilities - Decrease envt stimuli - Cluster cares to minimize stimulation - Swaddle nb to reduce self stimulation & protext skin from abrasions - Monitor & maintain F&Es - Admin frequent, small feedings of high-cal formula; can require gavage feedings - Elevate nb head during & following feedings & burp nb to reduce vom & aspirations - Try various nipples to compensate for poor suck reflex - Have suction avail to reduce risk of aspiration - For nb's withdrawing from cocaine, avoid eye contact & use vertical rocking & pacifier - Prevent infection - Initiate consult with child protective services - Consult lactation services to eval whether breastfeeding desired or contraindicated to avoid passing narcotics in breast milk. Methadone is not contraindicated during bf.

NSW Expected Findings - Methadone Withdrawal

- Manifestations of neonatal abstinence syndrome - Increased incidence of seizures - Sleep pattern disturbances - Stillbirth - SIDS - High birth weight (compared to with heroin exposure)

HR

110-160/min with brief fluctuations from this range depending on activity level (crying, sleeping) Apical pulse rate assessed for 1 full min, preferably when newborn sleeping Pediatric stethoscope head placed on 4th or 5th ICS at left midclavicular line over apex of newborn's heart Heart murmurs documented & reported

Expected lab values - Hgb

14-24 g/dL

Fats

15% of calls should come from fat (trigylcerides) Fat in breast milk is easier to digest than cow's milk

Expected lab values - Platelets

150,000 to 300,000/ mm^3

Expected weight

2,500-4,000 g 5.5-8.8 lb

Expected values - Bilirubin

24 hr: 2-6 mg/dL 48 hr: 6-7 mg/dL 3-5 days: 4-6 mg/dL

Chest circumference

30-33 cm 12-13 in

RR

30-60 breaths/min with short period of apnea (<15 sec) occuring most frequently during REM sleep Apnea >15 sec should be evaluated Crackles & wheezing are manifestation of fluid or infection in lungs Grunting & nasal flaring indicate resp distress

Expected head circumference

32-36.8 cm 12.6-14.5 in

Expected values - RBC count

4.8 x 10^6 to 7.1 x 10^6

Expected lab values - Glucose

40-60 mg/dL

Expected lab values - Hct

44% to 64%

Expected length

45-55 cm 18-22 in

BP

60-80 mmg Hg systolic 40-50 mm Hg diastolic

Protein

9 g/day from birth-6 months

Expected value - WBC count

9,000-30,000/mm^3

Temp

97.7-99.5 Avg is 98.6 Newborn at risk for hypothermia& hyperthermia until thermal regulation stabilizes. If newborn becomes chilled (cold stress), O2 demands may ^ & acidosis may occur

Postmature Infant

A newborn who is postmature is born after completion of 42wks of gestation. Postmaturity of infant can be associate with either of the following: - Dysmaturity (SGA or immature for gestational age) from placental degeneration & uteroplacental insufficiency - Continued growth of fetus in utero

RDS, Asphysxia, & Meconium Aspiration - Lab tests

ABGs CBC with differential Culture & Sensitivity of blood, urine, & cerebrospinal fluid BG Diagnostics: Chest x-ray

Physiologic Response of Newborn to Birth

Adjustments to extrauterine life occur as a newborn's resp & circulatory systems required to rapidly adapt to life outide uterus Establishment of respiratory function with cutting of umbilical cord is most critical extrauterine adjustment as air inflates lungs with first breath Circulatory changes occur due to changes in pressures of cv system related to cutting of umbilical cord as newborn breathes independently Three shunts (ductus arterious, ductus venosus, foramen ovale) functionally close during a newborn's transition to extrauterine life with flow of O2 blood in lungs & readjustment of atrial BP in heart.

Vitamin K (phytonadione)

Admin to prevent hemorrhagic disorders. Vit K not produced in GI tract of nb until day 7. Vit K produced in colon by bacteria once formula or breastmilk introduced. Admin 0.5-1 mg IM into vastus lateralis (Where muscle development adequate) soon after birth

Behavioral responses to pain

Alterations in sleep-wake cycles, feeding, or activity Fussiness or irritability Limb withdrawal; thrashing or fist-clenching; muscle rigidity or flaccidity Facial grimacing; chin quivering; furrowed brow; tightly closed eyes; open, square-shaped mouth Crying, groaning, or whimpering vocalizations

Circumcision Intraprocedure Anesthesia

Anesthesia is required for circumcision. Types: Ring block Dorsal-penile nerve blck Topical anesthetic (eutectic mixture of local anesthetics) Concentrated oral sucrose Nonpharm methods including swaddling & nonnutritive sucking can be used to enhance pain mgmt

HTT - Head - Fontanels

Anterior fontanel should be palpable & approx 5cm on avg & diamond-shaped. Posterior fontanel is smaller & triangle-shaped Fontanels should be soft & flat. Can bulge when newborn cries vomits, or coughs, but should be flat when they are quiet. Bulging fontanels at risk can indicate increased intracranial pressure, infection, or hemorrhage. Depressed fontanels can indicated dehydration

HTT - Anogenital

Anus should be present, patent & not covered by membrane Meconium should be passed within 24-48 H after birth Genitalia of male newborn should include rugae on scrotum Testes should be present in scrotum Male urinary meatus shold be located at penile tip Genitalia of female should include labia majora covering labia minor and clitoris, and are usually edematous Vaginal blood-tinged discharge can occur in female newborns, caused by maternal pregnancy hormones. This is an expected finding. A hymenal tag should be present. Urine should be passed within 24H after birth. Uric acid crystals will produce rust color in urine in first couple days of life.

HTT - Eyes

Assess eyes for symmetry in size & shape Each eye from inner to outer canthus & space between should equal 1/3 distance across both eyes to rule out chromosomal abnormalities such as Down syndrome Eyes usually blue or gray following birth Lacrimal glands immature with minimal or no tears Subconjunctival hemorrhages can result from pressure during birth Pupillary & red reflex are present Eyeball movements with demonstrate random, jerky movements

HTT - Extremities

Assess for full ROM, symmetry of motion, and spontaneous movements Extremities should be flexed Assess for bowed legs & flat feet, which should be present because lateral muscles are more developed than medial muscles. No click should be heard when abducting hips. Gluteal folds should be symmetrical. Soles should be well-lined over 2/3 of feet Nail beds shoud be pink & no extra digits present

HTT - Mouth

Assess for palate closure & strength of sucking Lip movements should be symmetrical Saliva should be scant Excessive saliva can indicate tracheoesophageal fistula Epstein's pearls (small whitish-yellow cysts found on gums & at junction of soft & hard palates) are expected findings. Result from accumulation of epithelial cells & diappear a few wks after birth. Tongue should move freely, by symmetrical in shape, & not protrude. A protruding tongue can be indication of Down syndrome. Soft & hard palate should be intact Gray-white patches on tongue & gums can indicate thrush, a fungal infection caused by Candida albicans, sometimes acquired from mother's vaginal secretions.

Circumcision Preprocedure Nursing Assessment

Assess for: - Fam history of bleeding tendancies - Hypospadias or epispadias - Ambiguous genitalia - Illness or infection

Newborn Infection, Sepsis - Nursing Care

Assess infection risks (review maternal health record) Monitor for clinical findings of opportunistic infections Monitor vitals continuously Monitor I&O and daily weight Monitor F&E status Monitor nb visitors for infection Obtain specimens (blood, urine, stool) to assist in identifying causative organism Initiate & maintain IV therapy as prescribed to admin electrolyte replacements, fluids, & meds Isolation precautions as indicated Admin meds as prescribed (antibiotics, antivirals, antifungals) Initiate & maintain resp support as needed Assess IV site for evidence of infection Provide nb care to maintain temp Clean & sterilize all equipment to be used Provide emotional support to family

Circumcision Postprocedure Nursing Assessment

Assess newborn for the following: - bleeding - first voiding Assess bleeding every 15-30 min for first hour, then hourly for next 4-6H

Assessment of NB Nutrition

Assessment of nb nutrition begins during pregnancy & continues after birth by reviewing parent & nb factors that effect feeding. Newborn: Maturity level History of labor & delivery Birth trauma Congenital defects Physical stability State of alertness Presence of bowel sound Parent: Previous experience breastfeeding Knowledge about bf Cultural factors Feelings about bf Physical features of breasts Physical/psychological readiness Support of fam & sig others

Congenital heart disease CHD

Atrial septal defects, ventricular septal defects, coarcation of aorta, tetralogy of Fallot (heart blood flow obstruction), transposition of great vessels, stenosis, atresia of valves

Client education - Breastfeeding cont.

Avoid nipple confusion in nb by not offering supplemental formula, pacifiers, or soothers until bf has been established (3-4 wks). Supplementation can be provided using supplemental device or syringe feeding if needed. If supplementation necessary, expressed breast milk is best. Always place nb on back after feedings Herbal products (fenugreek, blessed thistle) & prescription meds (metoclopramide) have been reported to ^ breast milk prod. Insufficient data to confirm or deny effect on lactation. Check with provider before taking OTC meds. Breast milk can be expressed using hand expression or a pump so nb can be fed using bottle or supplemental device - Pumps can be manual or electric or battery operated & pumped directly into bottle or freezer bag - One or both breasts can be pumped & suction adjustable for comfort

SGA Labs & Diagnostics

BG for hypoglycemia CBC shows polycythemia from fetal hypoxia & IU stress ABGs can be prescribed de to chronic hypoxia in utero due to pacental insufficiency Chest x-ray to rule out meconium aspiration syndrome

Postmature Infant - Lab Tests & Diagnostic Procedures

BG levels to monitor for hypoglycemia ABGs secondary to chronic hypoxia in utero due to placental insufficiency CBC to show polycythemia from decreased oxygenation in utero Hct elevated from polycythemia & dehydration Diagnostic procedures: - C-sec - Chest x-ray to rule out meconium aspiration syndrome

Preterm Newborn - Physical Assessment Findings

Ballard assessment showing physical & neuro assessment totaling less than 37wks gestation Periodic breathing consisting of 5-10 sec resp pauses, following by 10-15 sec compenatory rapid respirations Manifestations of increased resp effort and/or resp distress including nasal flaring or retractions of chest wall during inspirations, expiratory drunting, & tachypnea Apnea: A pause in resp 20 sec or greater Low birth weight Minimal subcut fat deposits head large in comparison w body, & small fontanels Wrinkled features w abundance of lanugo covering back, forearms, forehead, sides of face, and few or no creases on soles of feet Skull & rib cage that feel soft Eyes closed if nb born at 22-24 wks of gestation Weak grasp reflex Inability to coordinate suck & swallow; weak or absent gag, suck, & cough reflex; weak swallow Hypotonic muscles, decreased level fo activity, & weak cry for >24h Lethargy, tachycardia, & poor weight gain

Bathing - Client education

Bathing by immersion not done until nb's umbilical cord fallen off & circumcision healed if applicable. Wash area around cord taking care not to get cord wet. Move cleanest to dirtiest part of nb's body, beginning with eyes, face, & head; proceed to chest, arms, and legs; wash groin area last. Bathing shuld take place at convenience of parents but not immediately after feeding to prevent spitting up & vomiting Organize all equipment so newborn is not left unattended. Never leave nb alone in tub or sink. Make sure hot water heater set at 120.2 or less. Room should be warm & bath water should be 100.4. Test water for comfort with elbow prior to bathing newborn. Avoid drafts or chilling of newborn. Expose only body part being bathed & dry newborn thoroughly to prevent chilling & heat loss. Clean eyes using clean portion of wash cloth. Use clear water to clean each eye, moving from inner to outer canthus. Each area of nb's body should be washed, rinsed, & dried with no soap left on skin. Wrap newborn in towel, & swaddle them in football hold to shampoo head. Rinse shampoo from head & dry to avoid chilling. To cleanse uncircumcised penis, wash with soap & water & rinse penis. Foreskin should not be forced back or constriction can result. To cleanse circumcised penis, use warm water. Do not use soap until circumcision healed. Wash vulva by wiping from front to back to prevent contamination fo vagina or urethre from rectal bacteria. Applying fragrance-free, hypoallergenic, moiturizing emollient immediately after bathing can help prevent dry skin.

Bathing

Bathing can begin once newborn temp stabilizes at 97.7 Complete sponge bath should be postponed until thermoregulation stabilizes Gloves should be worn until nb's first bath to avoid exposure to body secretions

RDS, Asphysxia, & Meconium Aspiration - Meds

Beractant, calfactant, lucinactant Classification: Lung surfactant Intended effect: Restores surfactant & improves resp compliance for nbs who are premature & have RDS Nursing actions: - Perform resp assessment incl ABGs, resp rythm, & rate and skin color before & after admin - Provide suction to nb prior to admin - Assess endotrach tube placement - Avoid suctioning of endotrach tube for 1h after admin of med Factors that can accelerate lung maturation in fetus while in utero include increased gestational age, intrauterine stress, exogenou steroid use, & ruptured membranes

Term

Birth between beginning of wk 37 & prior to end of 42wks gestation 37-42 wks

Birth Trauma or Injury - Diagnostics, Care, Education

Birth injuries normally diagnosed by CT scan, x-ray of suspected area of fracture, or neuro exam to determine paralysis of nerves Nursing Care: - Review maternal hx of factors that can predispose newborn to injuries - Review Apgar scoring that might indicate possibility of birth injury - Perform frequent HTT assessments - Obtain vitals & temp - Promote parent-nb interaction as much as possible - Admin trtmt to nb based on injury & according to provider prescriptions Client Education: Discharge instructions- - Understand injury & mgmt of injury - Perform parent-nb bonding

Preterm Newborn

Birth occurs after 20wks & before completion of 37 wks gestation Late preterm birth occurs 34-36 6/7 wks Early term birth occurs 37-38 6/7 wks Preterm nbs are at risk for variety of complications due to immature organ systems. Degree of complication depends on gestational age. There is decreased risk of complication the closer the nb is to 40 wks Goals include meeting nb's growth & development needs & anticipating & managing assoc complications (RD, sepsis) Main priority in treating nbs who are preterm is supporting cardiac & resp systems as needed. Most nbs who are preterm are cared for in neonatal ICUs (NICU). Meticilous care & observation in NICU is necessary until nb can recieve oral feedings, maintain body temp, & weighs approx 4.4lbs

SGA

Birth weight at or below 10th percentile & who has IUGR Common complications: perineatal asphyxia, mecnium aspiration, hypoglycemia, polycythemia, instability of body temp

NSW Lab Tests

Blood tests should be done to differentiate between neonatal drug withdrawal & CNS disorders. CBC BG Thyroid-stimulating hormone, thyroxine, triiodothyronine Drug screen of urine or meconium Hair analysis

Postterm (postdate)

Born after completion of 42 wks gestation

Postmature

Born after completion of 42 wks of gestation with evidence of placental insufficiency

Preterm or premature

Born prior to 37 wks gestation

Bottle feeding- Client education

Bottles & accessories can be put in dishwasher, boiled, or washed by hand in hot soapy water using a food bottle & nipple brush. Wash lid of can of formula with hot soapy water & shake before opening Use tap water to mix concentrated or powder formula If water source questionable, tap water should be boiled first Pep formula can be refrigerated up to 48h. Check flow of formula from bottle to ensure not coming out too slow or too fast Do not use formula past expiration date on container Cradle newborn in arms in semi-upright position. Newborn should not be placed in supine position during bottle feeding because of danger of aspiration. Newborns who bottle feed do best when held close at 45* angle Place nipple on top of nb tongue Keep nipple filled with formula to prevent newborn from swallowing air Always hold bottle & never prop bottle for feeding Give newborn opportunities to burp several times during feeding Place newbon on back after feedings Discard any unused formula remaining in bottle when newborn finished feeding due to possibility of bacterial contamination Newborn is being adequately fed if gaining weight; bowel movements are yellow, soft and formed; and they are satisfied between feedings. - Infants usually have 6+ wet diapers a day. - Infants who consume breast milk usaully have 3+ BMs a day. Infants who receive formula hav less frequent BMs.

Client education - Breastfeeding cont...

Breast milk must be stored according to guidelines for proper containers, labeling, refrigerating, & freezing. Can be stored room temp under very clean conditions for up to 8H. an be refrigerated in sterile bottles for use within 8 days, or frozen in sterile containers in freezer compartment of refrigerator for up to 6 mo. Breast milk can be stored in deep freezer for up to 12 mo. Thawing milk in refrigerator for 24hrs is best way to preserve immuniglobulins present in it. It can also be thawed by holding container under running lukewarm water or placing in container of lukewarm water. Bottle should be rotated often, but not shaken when thawing in this manner. Thawing by microwave contraindicated because destroys some of immune factors & lysozymes contained in milk. Microwave thawing also leads to development of hot spots in milk because of uneven heating, which can burn newborn. Do not refreeze thawed milk Unused portions of breast milk mut be discarded after thawing or warming.

Newborn Nutrition

Breastfeeding Human pasteurized milk Human donor milk Formula-feeding Bottle feeding

Apgar scoring

Brief physical exam done immediately following birth to rule out abnormalities Score is assigned based on quick review of systems Done at 1 & 5mins of life Purpose is to assess adaptation to extrauterine life & allow nurse to intervene with appropriate nursing actions 0-3 indicates severe distress 4-6 indicates moderate difficulty 7-10 indicates minimal or no difficulty with adjustment

Preterm newborn - Lab tests & Diagnostic Procedures

CBC showing decreased Hgb & Hct as result of slow prod of RBCs Urinalysis & specific gravity ^ PT & aPTT with & tendency to bleed Serum glucose Calcium Bilirubin ABGs Diagnostic Procedure: - Chest x-ray - Head ultrasounds - Echocardiography - Eye exams

Bottle feeding - Formula

Can be adequate source of nutrition. Nb should be fed every 3-4H Parent should awaken nb to feed at least every 3h during day & 4h during night until newborn feeding well & gaining weight adequately. Then a feed-on demand schedule can be followed Teach parents how to prep formula (mix according to instructions), bottles, & nipples. Review importance of hand hygiene prior to formula prep. Teach parents about different forms of formula (ready-to-feed, concentrated, powder) & how to prep each correctly.

Jaundice

Can be physiologic or pathologic. Physiologic jaundice: - Considered benign(resulting from normal nb physiology of ^ bilirubin prod due to shortened lifespan & breakdown of RBCs, & liver immaturity). - Nb who has physiological jaundice exhibits increase in bilirubin levels 3-5 days afer birth, with rapid decline to 3mg/dL 5-10 days after birth Pathologic jaundice: - Result of underlying disease. - Appears before 24h of age or is persistent after day 14. - In term nb, bilirubin levels increase >0.5 mg/dL/hr, peak at >12.9 mg/dL, or is assoc with anemia & hepatosplenomegaly. - Usually caused by blood group incompatibility or infection, but can be result of RBC disorders.

Vital Signs

Checked in the following sequence: Respirations HR BP Temp Check RR before baby becomes agitated or active by use of stethoscope, thermometer, or BP cuff

NSW Diagnostic Procedures

Chest x-ray for FAS to rule out congenital heart defects

Congenital Anomalies - Expected Findings

Cleft lip/palat: opening in lip or palate Tracheoesphageal atresia: Excessive mucus secretions & drooling, periodic cyanotic episodes & choking, abdominal distention after birth, immediate regurgitation after birth Duodenal atresia: Abdominal distention, bilious vomiting, failure to pass meconium in first 24h PKU: Can result in cognitive impairment if untreated; not evident at birth but will be identified with neonatal screening Galactosemia: Can result in failure to thrive, cataracts, jaundice, cirrhosis of liver, sepsis, & cognitive impairment if untreated; this will not be evident at birth, but will be identified with neonatal screening Hypothyroidism: Can result in hypothermia, poor feeding, lethargy, jaundice, & cretinism if untreated; not evident at birth, but can be identified at 6 weeks by manifestations of bradycardia, abdominal distention, coarse dry hair, and thick dry skin, which can progress to delayed CNS development.

GI Problems

Cleft lip/palate, diaphragmatic hernia, imperforate anus, tracheoesophagea fistula/esophageal atresia (EA), duodenal atresia, omphalocele, gaastroschisis, umbilical hernia, intestinal obstruction

Musculoskeletal deformities

Clubfoot, polydactyly, developmental dysplasia of hip

HTT - Head - Cephalohematoma

Collection of blood between periosteum & skull bone it covers. Does not cross suture line. Results from trauma during birth such as pressure of fetal head against maternal pelvis in prolonged difficult labor or forceps delivery. Appears first 1-2 days after birth & resolves in 2-8 wks

Complications related to newborn home care

Complications stemming from improper understanding of discharge instructions can include: - Infected cord or circumcision from improper care or tub bahing too soon - Falls, suffocation, strangulation, burns resultng in injuries, fractures, aspiration, or death due to improper safety precautions - Resp infections due to passive smoke or inhaled powders - Improper or no use of car seat ressulting in injuries or death - Serious infections due to lack of nonadherence with immunization schedule

SGA - Risk factors

Congenital or chromosomal anomalies Maternal infections, disease, malnutrition Gestational htn or DM Maternal smoking, drug, alcohol use Multiple gestations Placental factors (small placenta, placenta previa, decreased placental perfusion) Fetal congenital infections (rubella, toxoplasmosis)

Congenital Anomalies - Teralogy of Fallot

Conserve the nb energy to reduce workload on heart Admin gavage feedings or give oral feedings with specialized nipples Elevate nb's head & shoulders to improve respirations & reduce cardiac workload Prevent infection Place nb in knee-chest position during resp distress

Nursing Care of Newborns

Consists of stabilization & resuscitation. Can include establishing patent airway, maintaining adequate O2, and thermoregulation for maintenance of body temp. Physical assessment (exam, measurements, monitoring labs) is done Q8H or as needed. Nursing interventions & family teaching are integrated into newborn's plan of care: - umbilical cord care - prophylactic measures - newborn screening - newborn feedings & bathing - fostering baby-friendly activities

Breast milk

Contains vits necessary for newborn nutrition. All infants who are breast fed or partially breast fed should recieve 400 IU vit D daily beginning in first few days of life Formula has vit D added, but supplements also recommended Parents who are breastfeeding who do not consume meat, fish, & dairy should provide B12 supplement to newborn

Diagnostic & Therapeutic Procedure Following Birth

Cord blood is collected at birth. Lab tests are conducted to determine ABO blood type & Rh status if parent's blood type is "O" or they are Rh-negative. A CBC can be done by capillary stick to eval for anemia, polycythemia (^ # RBCs), infection, or clotting problems. BG is checked to eval for hypoglycemia.

Basic ways to hold newborn

Cradle hold: Cradle newborn's head in bed of elbow. This permits eye-to-eye contact & is good position for feeding Upright position: Hold newborn upright & face toward holder while supporting head, upper back, buttocks Football hold: Support half newborn's body in holder's forearm with newborn's head & neck resting in palm of hand. Good position for bf & when shampooing nb's hair.

Benefits of breast feeding specific to nursing parent

Decreased pp bleeding & more rapid uterine involution Decreased risk for ovarian & blood cancer, T2DM, htn, hypercholesterolemia, cv diseas, & rheumatoid arthritis

Benefits of breast feeding specific to the infant

Decreased risk for: GI infection Celiac disease Asthma Lower RT infections Otitis media, SIDS Obesity in adolescence & adulthood T1 & T2 DM Acute lymphocytic & myeloid leukemia

Breastfeeding nursing interventions cont..

Demo 4 basic bf positions: 1) Football hold (under arm) 2) Cradle (most common) 3) Modified cradle (across lap) 4) Side lying Teach parents to observe nb for cues of fullness rather than being concerned about the time the feeding takes To prevent nipple trauma show parent how to insert finger in side of nb mouth to break suction from nipple prior to removing nb from breast Promote rooming-in effort Offer referral to bf support groups Contact lactation consultant to offer additional recs & support, esp to parents who have concerns about adequate breast mik or parents who have been unsuccessful with bf in past

Congenital Anomalies - Nursing Care

Dependent on type & extent of anomaly - Establish & maintain adequate respiratory status - Establish & maintain extrauterine circulation - Establish & maintain adequate thermoregulation - Admin meds as prescribed, such as thyroid replacement for hypothyroidism - Educate parents regarding preoperative & postoperative treatment procedures - Encourage parents to hold, touch, & talk to newborn - Ensure that parents provide consistent care to nb - Provide parents with info about parent groups or support systems

Nutrition - Cleft lip/palate

Determine most effective nipple for feedings. Can use specialized bottles, cups, syringes to feed infant Can acheive bf with changes in positioning Feed in upright position to decrease aspiration risk Feed nb slowly & burp frequently so do not swallow air. Cleanse mouth with water after feeding

Lab Tests - Serum bilirubin

Done on all newborns prior to discharge

Chromosomal abnormalities

Down syndrome

Postmature Infant - Continued growth of fetus in utero

Due to fact that placenta continues to function effectively & newborn becomes LGA at birth. This leads to dffuclty delivery, cephalopelvic disproportion, & high insulin reserves & insufficient glucose reserves at birth. Neonatal response can be birth trauma, perinatal asphyxia, clavicle fracture, seizures, hypoglycemia, and/or temp instability (cold stress)

Hemorrhage

Due to improper cord care or placement of clamp Nursing actions: - Ensure clamp is tight. If seepage of blood noted, second clamp should be applied. - Notify provider if bleeding continues

Fluid intake

During first two days of life, healthy newborns need 60-80mL/kg/day Days 3-7, fluid requirement is 100-150 mL/kg/day

Congenital Anomalies - Patent ductus arteriosus

Educate parents about surgical treatment

BP Cuff

Electronic method. BP can be done in all 4 extremeties if evaluating newborn for cardiac problems.

Hyperbilirubinemia - Lab Tests

Elevated serum bilirubin level can occur (direct & indirect bilirubin). Monitor nb bilirubin level Q4H until level returns to normal. Assess maternal & nb blood type to determine whether ABO incompatibility. Occurs if newborn has blood type A or B, and parent type is O. Review hgb& hct A direct Coombs' test reveals presence of antibody-coated (sensitized) Rh-positive RBCs in nb Check electrolyte levels for dehydration from phototherapy. Diagnostic procedures: - Transcutaneous bilirubin level is noninvasive method to measure nb bilirubin level

Hyperbilirubinemia

Elevation of serum bilirubin levels resulting in jaundice. Jaundice normally appears on head (esp sclera & mucous membranes), & then progresses down thorax, abdomen, & extremities.

HTT - Moro reflex

Elicit by allowing head and trunk of newborn in semisitting position to fall backward to an angle of at least 30* Newborn will symmetrically extend and then abduct arms at elbows, & fingers spread to form a "C" Complete response can be seen until 8 wks, body jerk only until 8-18 wks, and then absent by 6 months

HTT - Stepping

Elicit by holding newborn upright with feet touching flat surface. Newborn responds with stepping movements. Occurs birth to 4 wks

HTT - Plantar Grasp

Elicit by placing finger at base of newborn's toes. Newborn responds by curling toes downward. Expected at birth-8mo

HTT - Palmar Grasp

Elicit by placing finger in palm of newborn's hand. Newborn's fingers curl around examiner's fingers. Lessens by 3-4 mo

HTT - Sucking & rooting reflex

Elicit by stroking cheek or edge of mouth. Newborn turns head toward side that is touched & starts to suck. Usually disappears after 3-4 mo but can persist up to 1 yr

HTT - Babinski Reflex

Elicit by stroking outer edge of sole of foot, moving up toward toes. Toes will fan upward & out. Seen at birth to 1 yr

Congenital Anomalies - Cleft lip/palate

Encourage expression of parental concerns, grief, fears Monitor nb weight daily while hospitalized Monitor for manifestations of dehydration Encourage parental attachment Suction mouth & nose gently with bulb syringe as needed to clear airway Position infant to facilitate drainage of secretions Educate parents on feeding requirements of infant

Hyperbilirubinemia - Nursing Care cont.

Encourage parents to hold & interact w nb when phototherapy lights are off Monitor elim & daily weights for s/s dehydration Check nb axillary temp Q4H during phototherapy, as can become elevated Feed nb early & frequently, Q 3-4 . This will promote bilirubin excretion in stools. Encourage cont. bf of nb. Supplementation with formula can be prescribed. Maintain adequate fluid intake to prevent dehydration Reassure parents that most nbs experience some degree of jaundice Explain hyperbiirubinemia, causes, diagnostic tests, & trtmt to parent Explain nb's stool contains some bile that will be loose & green. Admin an exchange transfusion for nbs at risk for kernicterus

Cardiopulmonary resuscitation

Encourage parents to seek CPR training

Infection control

Essential in preventing cross-contam from nb to nb & between nb & staff. NBs at risk for infection first few months of life because immature immune systems Provide individual bassinets equipped with diapers, T-shirt, & bathing supplies All personnel who care for nb should scrub with antimicrobial soap elbows to finger tips before entering nursery. Between care of newborn, nurse should follow facility hygiene protocols. Cover gowns or specials uniforms used to avoid direct contact with clothes.

Calories

Essential to provde energy for growth, digestion, metabolism, & activity 0-3 months, 110 kcal/day 3-6 months, 100 kcal/day Breast milk & formula provide 20 kcal/oz

Newborn Wellness Checkups

Every nb should be seen/examined atprovider's office within 72h after discharge. Wellness checks recommended at 2-5 days, 1 mo, 2 mo, 4 mo, 6 mo, 9 mo, 12 mo, 15 mo, 18 mo, 2 yr, 2.5 yr, 3 yrs, 4 yrs, & every year thereafter. Review schedule for immunizations with patients. Stress important of receiving these immunizations on schedule for newborn to be protected against diptheria, tetanus, pertussis, hep b, haemophilus influenza, polio, measles, mupms, rubella influenza, rotavirus, pneumococcal & varicella.

NSW Expected Findings - Fetal Alcohol Syndrome

Facial anomalies: Small eyes, flat midface, smooth philtrum, thin upper lip, eye with wide-spaced appearance, epicanthal folds, strabismus (cross eyes), ptosis, poor suck, small teeth, cleft lip or palate Many vital organ anomalies such as heart defects,including atrial & ventricular septal defects, tetralogy of Fallot, patent ductus arteriosus Development delays & neurologic abnormalities Prenatal & postnatal growth delays Sleep disturbances

NSW - LT Complications

Feeding problems CNS dysfunction (cognitive impairment, cerebral palsey) Attention deficit disorder Language abnormailities Microcephaly Delayed growth & development Poor maternal-newborn bonding

Feeding

Feedings can be started immediately following birth Breast feeding intiated ASAP after birth as part of baby-friendly initiatives Formula feeding usually started at about 2-4H of age Newborn fed on demand which is normaly every 3-4H for bottle-fed newborns & more frequently for breastfed newborns. Monitor & document feedings per protocol

Convection

Flow of heat from body to cooler environmental air. Place bassinet out of direct line of a fan or AC vent , swaddle newborn in a blanket, & keep head covered. Any procedure done with newborn uncovered should be performed under radiant heat source Keep ambient room temp at 72-78*F

New Ballard Score Classification

Following physical assessment, classification of newborn by gestational age & birth weight is determined

Hypoglycemia

Frequently occurs in first few hrs of life secondary to use of energy to establish resps & maintain body heat Newborns of client who have DM & are small or large for gestational age; less than 34 wks of gestation; or late preterm newborns are at risk for hypoglycemia. Should have BG monitored within first 2h of life. Follow facility protcols regarding frequency of assessing BG levels Nursing actions: - Monitor for jitters; twitching; a weak, abnormal cry; irregular respiratory effort; cyanosis; lethargy; eye rolling; seizurs; BG level <40 mg/dL by heel stick - Have parent breastfeed immediately or give donor breast milk or formula to elevate BG levels. Brain damage can result if brain cells depleted of glucose.

Congenital Anomalies - Hydrocephalus

Frequently reposition nb head to prevent sores Measure nb head circumference daily Assess for manifestations of ^ intraranial pressure (vomiting, shrill cry)

Transesophageal Fistula

GI anomaly that an occur independently or together with an EA. TEA alone can include variety of abnormal connections between esophgus & trachea. TEF & EA combined include blind esophagus pouch and/or abnormal connection between esophagus & trachea. Presence of TEF places infant at risk for aspiration & resp complications. Health Promo & Disease Prevention: - TED can be detected & diagnosed during pretanal ultrasound

Congenital anomalies cont.

Generally identified soon after birth by Apgar scoring & brieg assessment indicating need for further investigation. Once identified, congenital anomalies are treated in pedi setting. Cleft lip/palate: Failure of lip or hard or soft palate to fuse Tracheoesophageal atresia: Failure of esophagus to connect to stomach Phenylketonuria (PKU): Inability to metabolize amino acid phenylalanine Galactosemia: Inability to metabolize galactose into glucose Hypothyroidism: Slow metabolism caused by maternal iodine deficiency or maternal antithyroid meds during pregnancy Neurologic anomalies (spina bifida): Neural tube defect in which vertebral arch fails to close Hydrocephalus: Excessive spinal fluid accumulation in ventricles of brain Patent ducturs arteriosus: Noncyanotic heart defect in which ductus arteriosus connecting pulm artery & aorta fails to close after birth Tetralogy of Fallot: Cyanotic heart defect characterized by ventricular septal defect, aorta positioned over ventricular septal defect, stenosis of pulm valve, & hypertrophy of right ventricle. Down syndrome: Trisomy 21, which is most common trisomic abnormality with 47 chromosomes in each cell.

Nutrition - Galactosemia

Give nb soy-based formula because galactose present in milk. Eliminate lactose & galactose in nb's diet. Breastfeeding also contraindicated.

Umbilical cord care

Goal is to prevent or decrease risk for infection or hemorrhage Cord clamp stays in place 4-48h Recommendations for cord care include cleaning cord with water (using cleanser sparingly if needed to remove debris) during initial bath of newborn. Assess stump & base of cord for erythema, edema, & drainage with each diaper change. Newborn's diaper should be folded down & away from umbilical stump. Bathing infant by submerging in water should not occur until cord has fallen off. Most cords fall off within 10-14 days of birth

Circumcision Intraprocedure Equipment

Gomco (Yellen) or Mogen clamp, or Plastibell device Provider applies Gomco or Mogen clamp to penis, loosens foreskin, & inserts cone under foreskin to provide cutting surface for removal of foreskin & to protect penis Provider slides plastibell device between foreskin & glans penis. Then ties a suture tightly around foreskin at coronal edge of glans. This applies pressure as excess foreskin removed from penis. After 5-7 days, Plastibell drops off, leaving clean, healed excision. No petroleum used for circumcision with the Plastibell

Intrauterine Growth Restriction (IUGR)

Growth rate does not meet expected norms

HTT - Head - Circumference

Head should be 2-3 cm larger than chest circumference. If head circumference > or = 4 cm larger than chest circumference , can be an indication of hydrocephalus (excessive cerebral fluid within brain cavity surrounding brain) If head circumference < or = 32 cm, can be an indication of microcephaly (abnormally small head)

Circumcision - Health benefits, risks, contraindications

Health benefits: - Easier hygiene - Decreased risk of STIs (HIV, HPV) - Decreased risk of penile cancer & cervical cancer in female partners Possible risks: - Hemorrhage - Infection - Inflammation or stenosis of urinary meatus - Urethral fistula - Adhesions or dehiscence of skin - Concealed penis Contraindications: - Hypospadias: Abnormal positioning of urethra on ventral under-surface of penis. Contraindicated because prepuce skin may be needed for surgical repair of the defect. - Epispadias: Urethral canal terminates on dorsum of penis. Contraindicated because prepuce skin may be needed for surgical repair of the defect. - Family history of bleeding disorders - Newborns who do not recieve vit k, making them more likely to experience bleeding at circumcision site.

HTT - Hearing

Hearing is similar to that of an adult once amniotic fluid drains from ears Newborns exhibit selective listening to familiar voices & rhythms of intrauterine life Newborn turns toward general direction of sound

Apgar scoring points breakdown

Heart rate: 0 = absent 1 = Slow, less than 100/min 2 = Greater than 100/min Respiratory rate: 0 = absent 1 = slow, weak cry 2 = good cry Muscle tone: 0 = Flaccid 1 = Some flexion of extremeties 2 = Well-flexed Reflex Irritabiltiy: 0 = None 1 = Grimace 2 = Cry Color: 0 = Blue, pale 1 = Pink body, cyanotic hand & feet (acrocyanosis) 2 = Completely pink

Interventions that maintain thermoregulation

Heat loss occurs by 4 mechanisms Conduction Convection Evaporation Radiaton

Lab Tests - Collecting Blood Samples

Heel stick blood samples obtained by nurse who dons clean gloves Warm newborn's heel first to ^ circulation Cleanse area with appropriate antiseptic & allow for drying Spring-activated lancet is used so skin incision made quickly & painlessly Outer aspect of heel should be used, & lancet should go no deeper than 2.4mm to prevent necrotizing osteochondritis resulting from penetration of bone with lancet Follow facility protocol for specimen collection, equipment to be used, & labeling of specimens Apply pressure with dry gauze (do not use alcohol because it will cause bleeding to continue) until bleeding stops, & cover with adhesive bandage Cuddle & comfort newborn when procedure completed to reassure nweborn & promote feelings of safety

GU Deformities

Hypospadias, epispadia, extrophy of bladder, ambiguous genitalia

Identification of newborn

Identification (using 2 identifiers) applied to newborn immedately after birth by nurse. Important safety measure to prevent newborn from being given to wrong parents, switched, or abducted. Newborn, pt & pt parter are identified by plastic ID wristbands with permanent locks that must be cut to be removed. Should include newborn's name, sex, date, & time of birth, & clients health record #. Newborn should have 1 band on ankle, 1 band on wrist. Newborn's footprints & pt's thumb prints are taken. Above info also included in footprint sheet. Each time newborn given to parents, ID band should be verified against pt's ID band. All facility staff who assist in caring for newborn are required to wear photo ID badges Newborn not to be given to anyone who does not have photo ID badge that distinguishes that person as a staff member of facility maternal-newborn unit. Many facilities have locked maternal-newborn units that require staff to permit enrance or exit. Some have sensor device on ID band or unmbilical cord clamp that sounds an alarm if newborn removed from facility.

Bottle feeding - Human/donor milk

If parent not able to produce breast milk, recommended alternative is pasteurized donor milk from milk bank. Obtain informed consent. However, often not readily accessible & commercial infant formula used. Donor milk might be prescribed for infants who have some disorders Caution client against purchasing donor milk from individuals due to risk of contamination

Lab tests - Hgb & Hct

If prescribed

Postmature Infant - Risk Factors

In most cases, cause of pregnancy that extends beyond 40wks gestation is unknown, but there is higher incidence in first pregnancies & in pts who have had previous postmature pregnancy.

Lab Tests - Other genetic testing

Includes testing for galactosemia (inability to digest galactose, causing sugar buildup in blood), cystic fibrosis (mucuous blocking alveoli), maple syrup urine disease (sweet odor from inability to break down amino acids), hypothyroidism, & sickle cell disease

NSW - Nursing care

Includes the following in addition to normal nb care: - Ongoing assessment of nb using neonatal abstinence scoring system assessment, as prescribed. - Elicit & assess nb's reflexes - Monitor nb's ability to feed & digest intake. Offer small, frequent feedings. - Swaddle nb with legs flexed - Offer non-nutritive sucking - Monitor nb's f&es with skin turgor, mucous membranes, fontanels, faily weight, & I&O - Reduce environmental stimuli (decrease lights, lower noise level)

Hyperbilirubinemia - Risk Factors

Increase RBC prod or breakdown Rh or ABO incompatibility Decreased liver function Maternal ingestion of diazepam, salicylates, or sulfonamides close to birth Maternal DM Oxytocin during labor Neonatal hyperthyroidism Ecchymosis or hemangioma Cephalohematomas Prematurity

Cold stress

Ineffective thermoregulation can lead to hypoxia, acidosis, & hypoglycemia. Newborns with resp distress at higher risk for hypothermia. Nursing actions: -Monitor for manifestations of cold stress (skin pallor with mottling and cyanotic trunk; tachypnea) - NB should be warmed slowly over period of 2-4h. Correct hypoxia by admining O2. Correct acidosis & hypoglycemia.

Newborn Infection, Sepsis (Sepsis Neonatorum)

Infection can be contracted by nb before, during, or after delivery. Newborns are more susceptible to microogs due to ltd immunity & inability to localize infection. Infection can spread rapidly into bloodstream. Nb sepsis is presence of microorgs or their toxins in the blood or tissues of nb during first month after birth. Manifestations of sepsis are subtle & can resemble other diseases; nurse often notices them during routine care of nb. Responsible: S. aureas, S. epidermis, E. coli, H. influenzae., steptococus beta-hemolytic Group B Prevention of infection & nb sepsis starts perinatally with maternal screening for infections, prophylactic interventions, & use of sterile & aseptic techniques during delivery. Prophylactic antibiotic treatment of eyes of all nbs and appropriate umbiical cord care also help prevent nb infection & sepsis

Other observations

Inspect for gross structural malformations

Clothing

Instruct parents about care for & choice of nb clothing Client education: - Choose flame-retardant fabrics - Wash clothes separately with mild detergent & hot water - Dress newborns lightly for indoors & on hot days - Too many layers of clothing or blankets can make nb too hot - On cold days, cover newborn's head when outdoors - General rule is to dress nb as parents would dress selves

Manifestations of illness to report

Instruct parents regarding manifestations of illness & report to them immediately - Temp >100.4 or <97.9 - Poor feeding or little interest in food - Forceful vomiting or frequent vomiting - Decreased urination - Diarrhea or decreased BMs - Labored breathing with flared nostrils or absence of breathing for >15 sec - Jaundice - Cyanosis - Lethargy - Inconsolable crying - Difficulty waking - Bleeding or purulent drainage around umbilical cord or circumcision - Drainage developing in eyes

Hyperbilirubinemia - Kernicterus

Irreversible, chronic result of bilirubin toxicity. NB demonstrates many of same manifestations of bilirubin encephalopathy With added hypotonia, severe cognitive impairments, & spastic quadriplegia.

Birth Trauma or Injury - Physical Assessment

Irritability seizures within first 72h, & decreased LOC are manifestaions of subarachnoid hemorrhage Facial flattening & unresponsiveness to grimace that accompanies crying or stimulation, as well as eyes remaining open, are findings to assess for facial paralysis A weak or hoarse cry is characteristic of laryngeal nerve palsy from excessive traction on neck Flaccid muscle tone can signal joint dislocations & separation during birth Flaccid musce tone of extemities suggests nerve-plexus injuries or long bone fractures Limited motion of arm, crepitus over clavicle, & absence of Moro reflex on affected side are manifestations of clavicular fractures Flaccid arm with elbow extended & hand roated inward, absence of Moro reflex on affected side, sensory loss over lateral aspect of arm, & in tact grasp reflex are manifestations of Erb-Duchenne paralysis (brachial paralysis) Localized discoloration, ecchymosis, petechiae, & edema over presenting part are seen with soft-tissue injuries

Benefits of breast feeding specific to families & society

Less expensive than formula, reduces annual hc cost, reduces envt effects related to disposal of formula packaging & equipment

HTT - Head - Caput Succedaneum

Localized swelling of soft tissues of scalp caused by pressure on head during labor Expected finding that can be palpated as soft edematous mass & can cross over suture line. Caput succedaneum usually resolves in 3-4 days & does not require treatment

Conduction

Loss of body heat resulting from direct contact with cooler surface. Preheat radiant warmer, warm a stethoscope & other instruments, & pad a scale before weighing newborn. Newborn should be placed directly on patient's chest & covered with warm blanket.

Evaporation

Loss of heat as surface liquid is converted into vapor Gently rub newborn dry with warm sterile blanket (adhering to standard precautions) immediately after delivery If thermoregulation unstable, postpone initial bath until newborn's skin temp is 97.7. When bathing, expose only 1 body part at a time, washing & drying thoroughly

Radiation

Loss of heat from body to cooler solid surface close to, but not in direct contact. Keep newborn & exam tables away from windows & ACs.

NSW Expected Findings - Heroin Withdrawal

Low birth weight SGA Manifestations of neonatal abstinence syndrome Increased risk of SIDS

HTT - Posture

Lying in curled-up position with arms & legs in moderate flexion Resistant to extension of extremities

Transesophageal Fistula - Patient- Centered Care

Maintain thermoreg, electrolyte balance, acid-base balance Nursing care: - Position supine with head of bed elevated - Orogastric tube to low continuous suction - Monitor for signs of resp distress Do not feed any infant who has excessive oral secretions with resp distress until provider consulted!! Meds: - Antireflux - Antacids Therapeutic Procedures: - Surgical intervention to correct specific defect Complications: - Resp distress - Depends on other anomalies present

NSW Expected Findings - Opiate Withdrawal

Manifestations of neonatal abstinence syndrome

Hypoglycemia - Risk factors

Maternal DM Preterm infant LGA or SGA Stress at birth (cold stress, asphyxia)

Congenital Anomalies - Risk Fators

Maternal age >40 Chromosome abnormalies (Down Syndrome) Viral infections (Rubella) Excessive body heat exposure during first trimester (neural tube defect) Meds & substance use during pregnancy Maternal obesity Radiation exposure Maternal metabolic disorders (phenyketonuria, DM) Poor maternal nutrition such as folid acid deficiency (neural tube defects) Newborns who are preterm Newborns who are SGA Oligohydraminos or polyhydraminos

Birth Trauma or Injury - Risk Factors

Maternal age: < 16 or >35 Fetal macrosomia Abnormal or difficult presentations Prolonged labor Precipitous labor Oligohydramnios Cephalopevlic disproportion Multifetal gestation Congenital abnormalities Internal FHR monitoring Forceps or vacuum extraction External version C-section

Preterm Newborn - Risk factors

Maternal gestation htn Multiple pregnancies closely spaced Adolescent pregnancy Lack of prenatal care Maternal substance use, smoking Previous history of preterm delivery Abnormalities of uterus Cervical incompetence Placenta previa Preterm labor Preterm premature rupture of membranes

Neonatal Substance Withdrawal

Maternal substance use during pregnancy (drugs or alcohol). Intrauterine drug exposure can cause anomalies, neurobehavioral changes, & evidence withdrawal in neonate. These changes depend on drug/drug combinations used, dosage, route of admin, metabolism & excretion by parent & fetus, and timing & length of drug exposure Occurs when parent uses drugs that have addictive propertie: illegal drugs, alcohol, tobacco, & prescription drugs Fetal Alcohol Syndrome FAS results from chronic or periodic intake of alcohol during pregnancy. Alcohol is considered teratogenic, so daily intake ^ risk of FAS. Newborns with FAS are at risk for specific congenital defects & LT complications

NSW - Risk Factors

Maternal use of substances prior to knowing pregnant Mternal substance use during pregnancy

Tape measure in centimeters

Measure from crown to heel of foot for length Measure head circumference at greatest diameter (occipital to frontal). Measure chest circumference beginning at nipple line & abdominal circumference above umbilicus

Pain Assessment

Measure newborn pain using combo of behavioral observation & physiological findings Several pain scales have been developed as a tool to measure newborn pain: - CRIES scale - Scale for Use in Newborns (SUN) - Neonatal Infant Pain Scale (NIPS)

Normal skin deviations

Milia: Small raised pearly or white spots on nose, chin, forehead. These may be present, but disappear spontaneously without treatment. Parents should not squeeze! Mongolian spots: Spots of pigmentation that are blue, gray, brown, or black. Commonly noted on back and buttocks. More commonly present on newborns who have dark skin & can be linked to genetic. Be sure parents are aware of Mongolian spots, and document location & presence Telangietatic nevi (stork bites): Flat pink or red marks that easily blanch & are found on back of neck, nose, upper eyelids, & middle of forehead. Usually fade by second year of life Nevus fleus (port wine stain): Capillary angioma below surface of skin that is purple or red, varies in shape & size, is commonly seen on face, & does not blanch or disappear. Erythema toxicum (erythema neonatorum): Pink rash that appears suddenly everywhere on body of a term newborn during first 3 wks. Frequently referred to as newborn rash. No treatment required.

Mineral content

Mineral content of commercial newborn formula & breast milk is adequate with exception of iron & fluoride Iron is low in all forms of milk, but is absorbed better from breast milk. Newborns who only breastfeed should be given iron supplements at 4mo of age & until able to consume iron-containing foods. Newborns who are formula-fed should recieve iron-fortified newborn formula until 12 months of age Fluoride levels in breast milk & formulas are low. A fluoride supplement should be considered after 6 months of age,depending on water supply.

Complications - Hypothermia

Monitor axillary temp. Healthy newborn temp avgs 98.6 with range of 97.7-99.5 If temp unstable, place newborn in radiant warmer & maintain skin temp at approx 97.7 Ideal method for promoting warmth & maintaining neonate's body temp for a stable newborn is early skin-to-skin contact with parent. If infant does not reain skin-to-skin with parent during first 1-2 H after birth, place thoroughly dried infant under radiant warmer or in warm incubator until body temp stabilizes.. Asses axillary temp every 1H until stable All exams & assessments should be performed while newborn is under radiant warmer or during skin-to-skin contact with parent.

Elimination

Monitor elimination habits Newborns should void once within 24h of birth Should void 6-8x/day after day 4 Meconium sould be passed within first 24h-48h after birth. Newborn will then continue to pass stool 3-4x/day depending on whether breastfed or bottle fed. Stools of breastfed nb's can be yellow & seedy. Should have at least 3 stools/day for first month. Stools are lighter in color & looser than stools of newborns who are formula-fed. Monitor & doc output. Keep peri area clean & dry. Ammonia in urine is irritating to skin & can cause diaper rash. After each diaper change, cleanse peri area with clear water or water with mild soap. Diaper wipes with alcohol should be avoided. Pat dry & apply triple antibiotic ointment, petroleum jelly, & zinc oxide, depending on facility protocol.

Circumcision Complications & Nursing Mgmt - Hemorrhage

Monitor for bleeding Provide gentle pressure on penis using small gauze square Gelfoam powder or sponge can be applied to stop bleeding If bleeding persists, notify provider that blood vessel might need to be ligated. Have nurse continue to hold pressure until provider arrives while another nurse prepars circumcision tray & suture materials

Circumcision Complications & Nursing Mgmt - Cold stress/hypoglycemia

Monitor for excessive loss of heat resulting in ^ respirations & lowered body temp Swaddle & feed newborn as soon as procedure over

NSW - Expected findings

Monitor nb for abstinence syndrome (withdrawal) & ^ wakefulness using neonatal abstinence scoring system that assesses for & score the following.: CNS: High-pitched, shrill cry; incessant crying; irritability; tremors; hyperactivity with ^ Moro reflex; ^ deep tendon reflexes; ^ muscle tone; disturbed sleep pattern; hypertonicity; convulsions Metabolic, vasomotor, & respiratory findings: Nasal congestion with glaring, frequent yawning, skin mottling, retractions, apnea, tachypnea >60/min, sweating, temp > 99 GI: Poor feeding; regurgitation (projectile vom); diarrhea; excessive, uncoordinated, constant sucking

Monitoring NB for adequate growth

Monitor newborn for adequate growth & weight gain - Weights done daily in nb nursery. Every nb should be seen & examined at provider's office within 3-5 days after discharge & again at 2 wks. Growth assessed by placing nb weight on growth chart. Adequate growth should be within 10th-90th percentile. Poor weight gain is <10th & too much is >90th - NB length & head circumference routinely monitored Assess parent's ability to feed nb whether by breast or bottle Calculate nb 24h I&O if indicated, to ensure adequate nutrition

Home safety cont.

Monitor safety of crib. Space between mattress & sides of crib should be <2 fingerbreadths. Slats on crib should be no more than 2.25in apart. Crib or playpen should be away from window blinds & drapery cords. Nbs can become strangled. Bassinet or crib should be placed on inner wall, not next to window, to prevent cold stress by radiation, Smoke detectors should be on every floor of home & should be checked monthly to ensure they are working. Batteries should be changed 2x yearly. Eliminate potential fire hazards. Keep crib & playpen away from ehaters, radiators, & heat vents. Linens could catch fire if come into contact with heat sources. Control temp & humidityof newborn's envt by providing adequate ventilation Avoid exposing nb to cig smoke in home or elsewhere. Secondhand exposure causes increased risk of developing resp illness. All visitors shoudl wash hands before touching nb. Any individual who has infection should be kept away from nb. Carefully handle nb. Do not toss up in air or swing by extremities. Do not shake.

Postmature Infant - Nursing Care

Monitor vital Admin & monitor IV fluids Moisturize skin with petrolatum-based ointment Use mechanical ventilation if necessary Admin O2 as prescribed Prep/assist with exchange transfusion if hct high Provide thermoregulation in isolette to avoid cold stress Provide early feedings to avoid hypoglycemia Identify & treat any birth injuries

Birth Trauma or Injury

Most are minor. A few are serious enough to be fatal. Skull: Linear fracture, depressed fracture Scalp Caput succedaneum (edema/bump), hemorrhage Intracranial: Epidural or subdural hematoma, contusions Spinal cord: Spinal cord transaction or injury, vertebral artery injury Plexus: Brachial plexus injury, Klumpke's palsy (claw-like hand) Cranial & peripheral nerve: Radial nerve palsy (limp wrist), diaphragmatic paralysis

Neurologic

Muscle tone & reflex reaction (Moro reflex); palpation for presence & size of fontanels & sutures; assessment of fontanels for fullness or bulge

Hypoglycemia

NB's source of glucose stops when cord is clamped. If have other physiological stress, can experience hypoglycemia due to inadequate gluconeogenesis or ^ use of glycogen stores Normal BG: 30-60 mg/dL Hypoglycemia differs for nb who is term vs preterm. Hypoglycemia in first 3 days of life in term nwborn is defined as BG <30mg/dL Untreated hypoglycemia can result in seizures, brain damage, or death

LGA Risk factors

NBs who are postmature Maternal DM during preg Genetic factrs Maternal obesity Multiparity

Positioning & holding of head

Nb has minimal head control Head should be supported when newborn is lifted because head larger & heavier than rest of body

Postmature Infant cont.

Nb who is postmature can either be SGA or LGA depending on how well placenta functions during last weeks of pregnancy. Nbs who are postmature have ^ risk of aspirating meconium passed by fetus in utero. Persistent pulmonary htn (persistant fetal circulation) is complication that can result from meconium aspiration. Interference in transition from fetal to neonatal circulation, & ductus arteriosus (connecting main pulmonary artery & aorta) & foramen ovale (shunt between right & left atria) remain open, & fetal pathways of blood flow continue.

Congenital anomalies

Nbs can be born with congenital anomalies involving all systems. Anomalies often diagnosed prenatally. Nurse should provide emotional support to parents whose nb is facing procedures or surgeries to correct the defect. When congenital anomalies are present at birth, they can involve any of body systems. Major anomalies causing serious problems include: - Congenital heart disease - Neurological defects - GI problems - Musculoskeletal deformities - GU deformities - Metabolic disorders - Chromosomal abnormalities

Newborn Complications

Neonatal substance withdrawal Hypoglycemia Respiratory distress syndrome (RDS)/asphyxia/meconium aspiration Preterm newborn Small for Gestational Age (SGA) Large for Gestational Age (LGA)/macrosomic newborn Postmature newborn Newborn infection/sepsis (sepsis neonatorum) Birth trauma or injury Hyperbilirubinema Congenital anomalies

Neurological defects

Neural tube defects, hydrocephalus, anencephaly, encephalocele, meningocele, myelomeningocele (spina bifida)

Congenital Anomalies - Expected Findings cont..

Neurologic anomalies (spina bifida): Protrusion of meninges or spinal cord Hydrocephalus: Enlarges head & bulging fontanels; sun-setting sign is common in which whites of eyes visible above iris Patent ductus arteriosus: Murmurs, abnormal HR or rhythm, breathlessness, & fatigue while feeding Tetralogy of Fallot: Resp difficulties, cyanosis, tachycardia, tachypnea& diaphoresis Down Syndrome: Oblique palpebral fissures or upward slant of eyes, epicanthal folds, flat facial profile with depressed nasal bridge & small nose, protruding tongue, small low-set ears, short broad hands with fifth finger that has one flexion crease instead of two, a deep crease across center of palm (simian crease), hyperflexibility, hypotonic muscles

First period of reactivity

Newborn alert, exhibit exploring activity, makes sucking sounds, & has rapid HR & RR HR can be as high as 160-180/min Will stabilize at baseline of 100-120/min during a period that lasts 30min after birth

Lab tests - Metabolic screening

Newborn genetic screening mandated in all states. Capillary heel stick should be done 24 hrs following birth. For results to be accurate, newborn must have received formula or breast milk for at least 24 hr. If newborn discharged before 24 hrs of age, test should be repeated in 1-2 wks. All states require testing for phenylketonuria (PKU). PKU is a defect in protein metabolism in which accumulation of amino acid phenylalanine can result in mental retardation. Treatment in first 2 mo can prevent mental retardation.

Interventions for stabilization & resuscitation of airway

Newborn is able to clear most secretions in air passages by cough reflex. Routine suctioning of mouth & then nasal passages with bulb syringe is done to remove excess mucus in resp tract. Newborns delivered by cesarean birth are more susceptible to fluid remaining in lungs than newborns delivered vaginally If bulb suctioning unsuccessful, use mechanical suction for clearing airway. Institute emergency procedure if airway does not clear Bulb syringe should be kept with newborn, & family should be instructed on use. Family members should be asked to perform demo to show they understand bulb syringe techniques. - Compress bulb before insertion into one side of mouth - Avoid center of mouth to prevent stimulating gag reflex - Aspirate mouth first, one nostril, then second nostril

New Ballard Score

Newborn maturity rating score set to assess neuromuscular & physical maturity Each individual assessment parameter displays at least 6 ranges of development along a continuum Each range of development within an assessment is assigned number value from -1 to 5 Totals are added to give a maturity rating in weeks gestation (ex: a score of 35 indicates 38wks gestation)

Second period of reactivity

Newborn reawakens, becomes responsive again, & often gags & chokes on mucus that has accumulated in mouth This period usually occurs 2-8 hrs after birth Can last 10 min- several hrs

HTT - Vision

Newborn should be able to focus on object 8-12" away from face. This is approx distance from mother's face when newborn is breastfeeding. Eyes are sensitive to light, so newborns prefer dim lighting. Pupils are reactive to light, & blink reflex is easily stimulated. Newborn can track high-contrast & prefers black and white patterns. Term newborns can see objects as far away as 2.5 feet. Within 2-3 months, can discriminate colors.

Period of relative inactivity

Newborn will become quiet & begin to rest & sleep. HR & RR will decrease This period will last 60-100 min after birth

Congenital Anomalies - Nursing Assessment

Newborn's ability to take in adequate nourishment Newborn's ability to eliminate waste products Vitals & axillary temp Newborn-parental bonding, observing parent's response to diagnosis of congenital defect, & encouraging to verbalize concerns

HTT - Taste

Newborns can taste & prefer sweet to salty, sour, or bitter

Crying - Client Education

Newborns cry when hungry, overstimulated, wet, cold, hot, tired, bored, or need to be burped. In time parents learn what nb cry means. Do not feed nb every time they cry. Overfeeding can cause stomach aches & diarrhea. Newborns often have fussy time of day when cry for no reason. Not always possible to stop crying & newborn might cry themselves to sleep.

HTT - Smell

Newborns have highly developed sense of smell, prefer sweet smells, & can recognize mother's smell

Feeding/elimination

Newborns ho receive breastmilk hould have 3+ BMs per day; formula-fed newborns are less frequent. Newborns who receive breast milk should have 6+ wet diaper per day; formula-fed infants should have similar number of voids.

HTT - Touch

Newborns should respond to tactile messages of pain & touch. Mouth, hands & soles of feet are most sensitive to touch in newborn.

Sleep-wake cycle

Newborns sleep approx 16-19h/day with periods of wakefulness gradually increasing Many parents believe adding solid food to nb's diet will help with sleep pattern. During first 6 mo of life, recomended to only breastfeed. Most nbs will sleep through night without feeding at 4-5mo of age. Provider will instruct parents about when to add solid foods.

Complications for newborn nutriton

Newborns who are sleepy: - unwrap newborn - change diaper - hold upright & turn them from side to side - talk to nb - massage nb's back & rub hands & feet - Apply cool cloth to face Newborns who are fussy: - Swaddle - Hold close, move, then rock gently - Reduce environmental stimuli - Place skin-to-skin

Nutritional needs - weight loss & gain

Normal newborn weight loss immediately after birth and subsequent weight gain should be as follows: - Loss of 5%-10% after birth (regain 10-14 days after birth) - Gain of 110 to 200 g (3.8-7oz) /week for first three months

HTT - Nose

Nose should be midline, fat, & broad with lack of bridge Some mucus should be present, but with no drainage Newborns are obligate nose breathers & do not develop response of opening mouth with nasal obstruction until 3 wks after birth. Therefore, nasal blockage can result in flaring of nares, cyanosis, or asphyxia Newborns sneeze to clear nasal passages

Preterm Newborn - Nursing care cont..

Observe nb for findings of dehydration or overhydration (resulting from IV nutrition & fluid admin) Dehydration: - Urine output <1mL/kg/hr - Urine Specific Gravity >1.015 - Weight loss - Dry mucous membranes - Absent skin turgor - Depressed fontanel Overhydration: - Urine output >3mL/kg/hr - Urine specific gravity <1.001 - Edema - Increased weight gain - Crackles in lungs - Intake greater than output

Hyperbilirubinemia - Nursing Care

Observe skin & mucous membranes for jaundice Monitor vitals Set up phototherapy if prescribed. - Maintain eye mask over nb eyes for protection of corneas & retinas - Keep nb undressed. For male nb surgical mask should be place over geitalia to prevent testicuar damage from heat & light waves. Be sure to remove metal strip from mask to prevent burning. - Avoid applying lotions or ointments to skin because they absorb heat & can cause burns - Remove nb from phototherapy Q4H & unmask eyes, checking for inflammation or injury - Reposition Q2H to expose all body surfaces to phototherapy lights & prevent pressure sores - Check lamp energy with photometer per facility protocol - Turn off phototherapy lights before drawing blood for testing Observe nb for effects of phototherapy - Bronze discoloration: Not serious complication - Maculopapular skin rash: Not serious complication - Development of pressure areas - Dehydration - Elevated temp

Hypoglycemia - Nursing Care

Obtain blood by heel stick for glucose monitoring Asymptomatic at risk nb who has bg level <25mg/dl in first 4 hr or <35 mg/dL from 4-24h of age, should be offered oral feedings to ^ levels to >45 mg/dL Initiate IV dextrose for symptomatic newborn Provide frequent oral and/or gavage feedings or continuous parenteral nutrition early after birth to treat hypoglycemia Monitor neonate's bg level closely per faciliy protocol Monitor IV if neonate unable to feed orally Maintain skin-to-skin contact to treat hypothermia

LGA Nursing Care For NB Who Is LGA Following Delivery

Obtain early & frequent heel sticks (BG testing) Initiate early feedings or IV therapy to maintain glcose levels within expected reference range Provide thermoreg with isolette. Identify & treat any birth injuries.

Circumcision Preprocedure Nursing Actions

Obtain signed informed consent from parents Gather & prep supplies Admin meds as prescribed Assist with procedure: - Place newborn on resting board & provide radiant heat source to prevent cold stress. Do not leave newborn unattended. Have bulb syringe readily available. - Comfort newborn as needed - Document time & type of circumcision, amt of bleeding, & newborn voiding following procedure

Hyperbilirubinemia - Acute bilirubin encephalopathy

Occurs when bilirubin deposited in brain. Occurs once all of binding sites for bilirubin used within body, resulting in necrosis of neurons. Bilirubin levels >25 mg/dL place nb at risk. This can result in permanent damage including dystonia & athetosis, upward gaze, hearing loss, cognitive impairments.

Breastfeeding

Optimal source of nutrition for newborns. Recommended exclusively for first 6 months of age. Newborns should be breastfed every 2 to 3 hrs. Parents should awaken newborn to feed at least every 3 hrs during day & every 4 hrs during night until newborn feeding well & gaining weight adequately. Should occur 8-12x in 24h. Then a feed-on-demand schedule can be followed. First few days after birth, newborn receive colostrum. Colostrum is secreted from breasts during pp days 1-3. Contains immunoglobulin A (IgA) which provides passive immunity to newborn.

Chest

PMI location; ease of breathing; auscultation for HR & quality of tones; resprations for crackles, wheezes, equality of bilateral breath sounds

Swaddling

Parents should be shown how to swaddle newborn Swaddling newborn snugly in a receiving blanket helps newborn feel more secure. Swaddling brings newborn's extremities in closer to trunk, which is similar to intrauterine position.

Advantages of breastfeeding

Parents should receive factual info about nutritional & immunological needs of newborn. Present info about both breastfeeding & bottle feeding in nonjudgmental manner. Optimal time to provide nb nutritional info is during pregnancy, so parents can make decision prior to hospital admission.

Lab tests - BG for hypoglycemia

Per facility policy or as prescribed

Initial assessment

Perform quick initial assessment to review newborn's systems & observe for life-threatening abnormalities & resp issues - External Assessment - Chest - Abdomen - Neuro - Other observations

Preterm Newborn - Nursing Care

Perform rapid initial assessment Perform resuscitative measures as needed Monitor nb vitals Assess ability to consume/digest nutrients. Before feeding by breast or nipple, nb must have intact gag reflex & be able to suck & swallow to prevent aspiration Monitor I&O and daily weight Monitor nb for bleeding from puncture sites & GI tract Ensure & maintain thermoreg in preterm nb by using radiant heat warmer Manifestations of hypothermia: Apnea, cyanosis, hypoglycemia, feeding intolerance, lethargy, irritability, bradycardia Admin resp support measures such as surfactant and/or O2 admin Admin parenteral or enteral nutrition & fluids as prescribed (most preterm nbs <34 wks of gestation will receive fluids either by IV and/or gavage feedings). Provide for nonnutritive scking, scuh as using pacifier while gavage feeding. Minimize nbs stimulation. Cluster nursing care. Touch newborn very smoothly & lightly. Keep lighting dim & noise levels reduced.

Gestational age assessment

Performed within 48h of life Neonatal morbidity & mortality are related to gestational age & birth weight Gestational age assessment involves taking measurements of newborn & using New Ballard Score. New Ballard Score provides estimation of gestational age & baseline to assess growth & development

Metabolic disorders

Phenylketonuria, galactosemia, hypothyroidism

Hyperbilirubinemia - Therapeutic Procedures & Client Education

Phototherapy: nb's bilirubin should start to decrease w/in 4-6h after starting treatment Education: Discharge instructions- - Remember & adhere to nb plan of care - Infants with low-moderate risk of hyperbiirubinemia should receive f/up care within 2 days. Infants at higher risk should be seen w/in 24h.

Newborn Infection, Sepsis - Expected Findings

Physical Assessment: - Temp instability - Suspicious drainage (eyes, umbilical stump) - Poor feeding pattern (weak suck, decreased intake) - Vomiting & diarrhea - Hypoglycemia , hyperglycemia - Abdominal distention - Apnea,retractions, grunting, nasal flaring - Decreased O2 sat - Color changes (pallow, jaundice, petechiae) - Tachycardia or bradycardia - Tachypnea - Low BP - Irritability & seizure activity - Poor muscle tone & lethargy Lab tests: - CBC with differential, c-reactive protein - Blood, urine, cerebrospinal fluid culture & sensitivities - Chemical profile to show F&E imbalance

Breastfeeding nursing interventions

Place nb skin-to-skin on parent's chest immediately after birth. Initiate breastfeeding ASAP within first 30min following birth. Explain bf technique to parent. Have parent wash hands, get comfortable, & have caffeine-free, nonalcoholic fluids to drink during breastfeeding. Explain let-down reflex (stim of maternal nipple releases oxytocin that causes let-down of milk) Express a few drops of colostrum or milk & spread over nipple to lubricate nipple & entice nb Show parent proper latch-on position. Have them support breast in one hand with thumb on top & four fingers underneath. With nb mouth in front of nipple, nb can be stimulated to open mouth by tickling lower lip with tip of nipple.

Postmature Infant - Dysmaturity from placental degeneration & uteroplacental insufficiency

Placenta functions effective for approx 40 wks resulting in chronic fetal hypoxia & fetal distress in utero. Fetal response is polycythemia (^ # RBCs), meconium aspiration, and/or neonatal resp problems. Perinatal mortality higher when postmature placenta fails to meet increased O2 demands of fetus during labor.

Sleep-wake cycle - Client education

Placing nb supine for sleeping greatly decreases risk of SIDS Keep nb envt quiet & dark at night Place nb in crib or basisnet to sleep. Nb should never sleep in parents' bed due to risk of suffocation. Most nbs get their days & nights mixd up. Basic suggestions for helping develop predictable routine: - Bring nb out into center of action in afternoon & keep there until bed time - Bathe right before bed so feel soothed - Give last feeding around 2300 then place in crib or bassinet When awake, nb can be placed on abdomen to promote muscle development for crawling. Should be supervised. For nighttime feedings & diaper changes, keep small night light on to avoid having to turn on bright lights. Speak softly & handle nb gently so they go back to sleep easily.

Hypoglycemia - Expected Findings

Poor feeding Jitteriness/tremors *Hypothermia* *Weak cry* Lethargy *Flaccid muscle tone* Seizures/coma Irregular respirations Cyanosis Apnea Labs: Obtain lab specimen to verify BG finding <45mg/dL

Preterm newborn - Nursing care cont.

Position nb in neutral flexion with extremities close to body to conserve body heat. Prone & side-lying positions preferred to supine with body containment using blanket rolls & swaddling, but only in nursery under monitored supervision Perform skin assessment tool daily to minimize risk of skin breakdown. Encourage skin-to-skin contact (Kangaroo care) whenever possible to reduce preterm infant stress. Protect newborn against infection by enforcing hand hygiene & gowning procedures. - Equipment should not be shared with other newborns - Evidence of infection: Temp instability, lethargy, irritability, cyanosis, bradycardia, tachycardia, apnea or tachypena, feeding intolerance, glucose instability

Head-To-Toe

Posture Skin Head Eyes Ears Nose Mouth Neck Chest Abdomen Anogenital Extremities Spine Reflexes Senses Pain

New Ballard Score - Neuromuscular Maturity

Posture ranging from fully extended to fully flexed 0-4 Square window formation with neonate's wrist -1 to 4 Arm recoil, where neonate's arm is passively extended & spontaneously return to flexion 0-4 Popliteal angle, which is degree of angle to which newborn's knee can extend -1 to 5 Scarf sign, which is crossing neonate's arm over chest -1 to 4 Heel to ear, which is how far neonate's heels reach to their ears -1 to 4

Newborn Infection, Sepsis - Risk Factors

Premature rupture of membranes Prolonged labor Toxoplasmosis rubella, cytomegalovirus, herpes (TORCH) Chorioamnionitis Low birth weight Maternal substance use Maternal UTI Meconium aspiration HIV transmitted from parent to nb perinatally through placenta & postnatally through breast milk

NSW Expected Findings - Tobacco

Prematurity Low birth weight Increased risk for SIDS Increased risk for bronchitis Pneumonia Developmental delays

Congenital Anomalies - Diagnostic & Therapeutic Procedures

Prenatal screening for congenital anomalies can be done by ultrasound & multiple-marker screening (triple & quad screen) Confirmation of diagnosis depends on anomaly Prenatal diagnosis or confirmation of congenital anomalies often made by amniocentesis, chorionic villi sampling, or ultrasound Pulse ox reading for CHD Routine testing for newborns for metabolic disorders: - Guthrie test for PKU done to show elevations of Phenylalanine in blood & urine. Not reliable until newborn has ingested sufficient amts of protein. - Monitor blood & urine levels of galactose (galactosemia) - Measure thyroxine (hypothyroidism) - Cytologic studies (karyotyping of chromosomes) such as buccal smear, uses cells scraped from mucosa from inside nb's mouth

LGA Nursing Care Prior to Delivery

Prep cient for possible vacuum assisted or c-sec Prepare to place pt in McRoberts position (lithotomy pos with legs flexed to chest to maximize pelvic outlet) Prep to apply suprapubic pressure to aid in delivery of anterior shoulder which is located interior to maternal symphysis pubis Assess nb for birth trauma

NSW Expected Findings - Marijuana Withdrawal

Preterm birth Intrauterine growth restriction LT deficits in attention, cognition, memory & motor skills

RDS, Asphysxia, & Meconium Aspiration - Risk Factors

Preterm gestation Perinatal asphyxia (meconium staining, cord prolapse, nuchal cord) Maternal DM Premature rupture of membranes Maternal use of barbituates or narcotics close to birth Maternal hypotension C-sec without labor Hydrops fetalis (massive edema of fetus caused by hyperbilirubinemia) Maternal bleeding during 3rd trimester Hypovolemia Genetics: White males

NSW Expected Findings - Amphetamine Withdrawal

Preterm or SGA Drowsy Jittery Sleep pattern disturbances Respiratory distress Frequent infections Poor weight gain Emotional disturbances Delayed growth & develpment

Assessment of family readiness for home care of newborn

Previous newborn experience & knowledge Parent-newborn attachment Adjustment to parental role Social support Educational needs Sibling rivalry issues Readiness of parents to have home & lifestyle altered to accommodate newborn Parent's ability to verbalize & demo newborn care following teaching

Erythromycin

Prophylactic eye care is mandatory instillation of antibiotic ointment into eyes to prevent opthalmia neonatorum Infections can be transmitted during descent through birth canal. Ophthalmia neonatorum is caused by Neisseria gonorrhoeae or Chalamydia trachomatis & can cause blindness.

Congenital Anomalies - Neurologic Anomalies (spina bifida)

Protect membrane with sterile coverin g& plastic to prevent drying Observe for leakage of cerebrospinal gluid Handle nb gently by positioning them prone to prevent trauma Prevent infection by keeping area free from contamination by urine & feces Measure circumference of nb head to identify hydrocephalus Assess nb for ^ intracranial pressure

HTT - Habitation

Protective mechanism whereby the newborn becomes accustomed to environmental stimuli. Response to a constant or repetitive stimulus is decreased. This allows newborn to select stimuli that promotes continued learning, avoiding overload.

Home safety

Provide community resources to clients who might need ongoing assessment & instruction on newborn care (adolescent parents). Never leave nb unattended with pets or other small children Keep small objects (coins) out of reach of nb due to choking hazard Never leave nb alone on bed, couch, or table Nbs move enough to reach edge & fall off Never place nb on stomach to sleep during first few months of life. Back-lying is position of choice. Nb can be placed on abdomen when awake & supervised. Never provide nb with soft surface to sleep on (pillows or water bed). Mattress should be firm. Never put pilows, toys, bumper pads, or loose blankets in crib Crib linens should be tight-fitting. Do not tie anything around neck

Family education

Provide fam ed & promote fam-nb attachment Provide fam ed while performing all nursing care. Encourage fam involvement, allowing parent to perform nweborn care with direct supervision & support from nurse Encourage parents to hold nb so they can experience eye-to-eye contact and interaction Foster sibling interaction in newborn care

Intervening for newborn nutrition

Provide parent with educaton about feeding-readiness cues exhibited by NBs & encourage parent to begin feeding nb upon cues rather than waiting until nb is crying. Cues include: - Hand-to-mouth or hand-to-hand movements - Sucking motions - Rooting - Mouthing

Hep B Immunization

Provides protection against Hep B Recommended to be admin's to all NBs Informed consent must be obtained For NBs born to healthy clients, recommended dosage schedule is at birth, 1 mo, & 6 mo. For parents infected with Hep B: Hep B immonoglobulin & Hep B vaccine given w/in 12h of birth. Hep B vaccine given alone at 1 month, 2 months, & 3 months. Do NOT give vit K & Hep B vaccine in same thigh!!!

Nursing breastfeeding interventions

Provision of adequate cals & fluids to support breastfeeding Rooming in should be encoraged as part of baby-friendly initiatives Lactation consultants can improve success in breastfeeding Encourage breastfeeding through first 12 months of life

Nursing discharge teaching

Pts & newborns usually discharged 48h after vag delivery, or 72h after c-sec

Respiratory Distress Syndrome, Asphysxia, & Meconium Aspiration

RDS occurs as result of surfactant deficiency in lungs & is characterized by poor gas exchange & ventilatory failure Surfactant is a phospholipid that assists in alveoli expansion Surfactant keeps aveoli from collapsing & allows gas exchange to occur Atelectasis (collapsing of portion of lung) increases work of breathing. As result, respiratory acidosis & hypoxemia can develop Birth weight alone is not an indicator of fetal lung maturity Complications from RDS are related to O2 therapy & mechanical ventilation - Pneumothorax - Pneumomediastinum - Retinopathy of prematurity - Bronchipulmonary dysplasia - Infection - Intraventricular hemorrhage

Benefits of breastfeeding

Reduces risk of infections by providing IgA antibodies, lysozymes, leukocutes, macrophages, & lactoferrin that prevents infections. Promotes rapid brain growth due to large amounts of lactose. Provides protein and nitrogen for neurological cell building. Contains electrolytes and minerals. Easy to digest. Inexpensive. Reduces incidence of SIDS, allergies, obesity Promotes mother-infant bonding.

Complications - Inadequate O2 Supply

Related to obtructed airway, poorly functioning cardiopulmonary system, or hypothermia Monitor respirations for indication of cyanosis (changes in skin, mucous membrane color) Stabilize body temp or clear airway as indicated, admin O2, & if needed, prepare for resuscitation

Preterm newborn - Client education

Remain informed about & engaged in care of preterm nb

Circumcision Postprocedure Nursing Actions

Remove newborn from restraining board & swaddle to provide comfort Monitor for bleeding & voiding per facility protocol. Apply gauze lightly to penis if bleeding or oozing is observed Fan-fold diapers to prevent pressure on cirumcised area Liquid acetaminophen 10-15mg/kg can be admin'd orally after procedure & repeated Q 4-6H as prescribed for maximum of 30-45 mg/kg/day Provide discharge instructions to parents about manifestations of infection, comfort measures, meds, & when to notify provider

Newborn hearing screening

Required in most states. Screened so hearing impairments ca be detected & treated early.

Preterm NB - Complications

Respiratory distress syndrome: Decreased surfactant in alveoli occurs, regardless of NB's birth weight Bronchopulmonary dysplasia (BPD): Causes lungs to become stiff & noncompliant, requiring nb to receive mechanical ventilation & oxygen. BPD is also commonly caused by mechanical ventilation. oemtimes difficult to remove nb from ventilation & O2 after initial placement Aspiration: Result of nb who is premature not having an intact gag reflex or ability to effectively suck or swallow Apnea of prematurity: Result of immature neuro & chemical mechanisms Intraventricular hemorrhage: Bleeding in or around ventricles of brain Retinopathy of prematurity: Disease caused by abnormal growth of retinal blood vessels & is complication assoc with O2 admin to newborn. Can cause mild to severe eye & vision probs. Patent ductus arteriosus: Occurs when ductus arteriosus reopens after birth due to neonatal hypoxia, or when ductus arteriosus does not close after birth. Necrotizing enterocolitis: Inflammatory disease of GI mucosa due to ischemia. Results in necrosis & perforation of bowel. (Short-gut syndrome can be result secondary to removal of most or part of small intestine due to necrosis) Additional complications: Inefction, hyperbilirubinemia, anemia, hypoglycemia, delayed growth & development

Oral & Nasal suctioning

Review correct technique with parents

Transesophageal Fistula - Risk Factors, Expected Findings

Risk Factors: History of polyhydraminos Cardiac anomaly Cleft lip/palate Neural tube defects Expected findings: -Depends on specific defect present - Excessive oral secretions - Drooling - Feeding intolerance - Resp distress & cyanosis (fistula can cause air to bypass lungs & go into stomach) Diagnostic Procedures: Prenatal ultrasound

Risk Factors for Impaired NB Nutrition

Risk factors for failure to thrive (nb) can be related to nb or parent Newborn factors: - Inadequate bf - Illness/infection - Malabsorption - Other conditions that ^ energy needs Maternal factors: - Inadequate or slow milk prod - Inadequate emptying of breast - Inappropriate timing of feeding - Inadequate breast tissue - Pain with feeding - Hemorrhage - Illness/infection

Abdomen

Rounded abdomen & umbilical cord with 1 vein & 2 arteries

Scale with protective cover in place

Scale should be at 0; weight should include pounds, ounces, grams

Carbs

Should be 40-50% of newborn's caloric intake Most abundant carb in breast milk or forumula is lactose

HTT - Chest

Should be barrel-shaped Resps are primarily diaphragmatic Clavicles should be intact Retractions should be absent Nipples should be prominent, well formed, and symmetrical Breast nodules can be 3-10mm

HTT - Neck

Should be short, thick, surrounded by skin folds, & exhibit no webbing Should move freely side to side & up and down Absence of head control can indicate prematurity or Down syndrome

Circumcision Postprocedure Client Education

Signed informed consent needed Newborn will not be able to be bottle fed for up to 2-3H prior to procedure to prevent vomiting and aspirations. Newborns can be breastfed up until procedure. Newborn is restrained on board during procedure Keep area clean. Change newborn's diaper at least Q4H, & clean penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24H after circuscision to keep diaper from adhering to penis Avoid wrapping penis in tight gauze, which can impair circulation to glans Do not give tub bath until circumcision healed. Until then, trickle warm water gentle over penis. Notify provider if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying Film of yellowish mucus can form over glans by day 2. Do not wash it off. Avoid using premoistened towelettes to clean penis because they contain alcohol Newborn can be fussy or can sleep several hours after circumcision. Provide comfort measures for 24-48H, to include acetaminophen a prescribed. Should heal completely w/in a couple weeks Report any frank bleeding, foul-smelling draininage, or lack of voiding to provider

HTT - Skin

Skin color should be initially deep red to purple, with acrocyanosis Should fade to congruent to newborn genetic background Secondary to increased bilirubin, jaundice can appear 3rd day of life, but then decrease spontaneously Turgor should be quick, indicating well-hydrated. Should spring back immediately when pinched. Texture should be dry, soft, & smooth indicating good hydration. Cracks in hands & feet may be present. In full-term newborns, desquamation (peeling) occurs a few days after birth Vernix caseosa (protective, thick, cheesy covering) amount vary, with more present in creases & skin folds

External Assessment

Skin color, peeling, birthmarks, foot creases, breast tissue, nasal patency, meconium staining (can indicate fetal hypoxia)

Physical maturity

Skin texture, ranging from sticky & transparent, to leathery, cracked, wrinkled -1 to 5 Lanugo presence & amt, ranging from none, sparse, abundant, thinning, bald, or mostly bald -1 to 4 Plantar surface creases, ranging from less than 40mm to creases over entire sole -1 to 4 Breast tissue amount, ranging from imperceptible to fill areola with a 5-10mm bud -1 to 4 Eyes and ears for amt of eye opening & ear cartilage present -1 to 4 Genitalia develpment, ranging from flat to smooth scrotum to penduous testes with deep rugae for males -1 to 4 and prominent clitoris with glat labia to labia majora covering labia minora and clitoris for female -1 to 4

Sleep

Sleep-wake state are variations of consciousness in nb consisting of 6 states along a continuum comprised of deep sleep, light sleep, drowsy, quiet alert, active alert, & crying Newborns sleep approximately 16-19hrs/day with periods of wakefulness gradually increasing. Newborns are positioned supine, "safe sleep", to decrease incidence of sudden infant death syndrome (SIDS). No bumper pads, loose linens, or toys should be in bassinet Parents should sleep in close proximity but not in shared space. Higher indicence rates noted for SIDS & suffocation with bed sharing/co-sleeping Educate parents about need for immunizations as a measure to prevent SIDS

Failure to thrive

Slow weight gain. NB falls below 5th percentile on growth chart. Newborns who are breastfeeding: - Evaluate positioning & latch-on during bf - Massage breast during feeding - Determine feeding patterns & length of feedings - If newborn spitting up, can have allergy to dairy. Parent might need to eliminate dairy from diet. Instruct them to consume other food sources high in calcium or calcium supplements. Newborns who are formula feeding: - Evaluate how much & how often newborn is feeding - If newborn is spitting up or vomiting, can have allergy or intolerance to cow's milk-based formula & can require soy-based formula

Solids

Solids are not introduced until 6 month of age. If introduced too early, food allergies may develop.

Nutrition - PKU

Specialized synthetic formula in which phenylalanine is removed or reduced. Parent should restrict meat, dairy, diet drinks (artificial sweeteners), and protein during pregnancy. Aspartame must be avoided.

HTT - Spine

Spine should be straight, flat, midline, & easily flexed

Respiratory Complications

Stabilize and/or give resuscitation to newborn Monitor for clinical findings of resp complications Bradypnea: = or < 30/min Tachypnea: = or > 60/min Abnormal breath sounds: expiratory grunting, wheezes, crackles Respiratory distress: Nasal flaring, retractions, grunting, gasping, labored breathing

Complications - Airway obstruction related to mucus

Suction mouth & then nose with bulb syringe Mouth should be suctioned first to prevent aspiration as nose suctioned

RDS, Asphysxia, & Meconium Aspiration - Nursing Care

Suction nb mouth, trachea, & nose as needed Maintain thermoregulation Provide mouth & skin care Correct respiratory acidosis with ventilatory support Correct metabolic acidosis by admin sodium bicarb Maintain adequate O2 , prevent lactic acidosis, & avoid toxic effects of O2 Monitor lab resuts, I&O, & weight gain to eval hydration Decrease stimuli

SGA Nursing care & client education

Support respiratory efforts & suction nb as needed to maintain open airway Provide neutral thermal envt (isolette or radiant heat warmer) to prevent cold stress Initiate early feedings (nb who is SGA will require more frequent feeding) Admin parenteral nutrition if necessary Maintain adequate hydration Conserve nb energy level Prevent skin breakdown Protect nb from infection Provide support to parents & fam Education: Participate in caring for nb. Anticipate home care needs.

Circumcision

Surgical removal of foreskin of penis Newborn's family makes choice regarding whether to circumcise depending on health, hygiene, religion (jewish male 8th day of life), tradition, culture, or social norms. Parent should make well-informed decision in consultation with provider Circumcision should not be done immediatly following birth because newborn's level of vit k is at low point & newborn would be at risk for hemorrhage. Also at ^ risk for cold stress. Usually performed within first few days of life, but may be postponed due to cultural reasons or for preterm or ill newborns.

HTT - Head - Sutures

Sutures should be palpable, separated, & can be overlapping (molding), a normal occurence resulting from head compression during labor

Crying - Quieting techniques

Swaddling Close skin contact Nonnutritive sucking with pacifier Rhythmic noises to stimulate utero sounds Movement (car ride, vibrating chair, infant swing, rocking nb) Placing on stomach across holder's lap while gently bouncing legs En face position for eye contact (parents' & nbs' faces about 30cm/12in apart & in same plane) Stimulation

RDS, Asphysxia, & Meconium Aspiration - Physical Assessment Findings

Tachypnea (>60/min) Nasal flaring Expiratory grunting Retractions Labored breathing with prolonged expiration Fine crackles on auscultation Cyanosis Unresponsiveness, flaccidity, & apnea with decreased breath sounds (manifestations of worsened RDS)

Bathing

Teach parents proper nb bathing techniques by demo & have them do return demo After initial bath, nb's face, diaper area, & skin folds cleansed daily. Complete bathing performed two to three times per week using mild soap.

More thermoregulation interventions

Temp stabilizes at 98.6 within 12h after birth if chilling prevented. Best method for promoting & maintaining newborn temp is early skin-to-skin contact with parents

Thermoregulation

Thermoregulation provides neutral thermal envt that helps newborn maintain normal core temp with minimal O2 consumption & caloric expenditure. Newborn has relatively large surface-to-weight ratio, reduced metabolism per unit area, blood vessels close to surface, & small amts of insulation. Newborn keeps warm by metabolizing brown fat, which is unique to newborns but only within very narrow temp range. Becoming chilled (cold stress) can ^ newborn's O2 demands and rapidly use up brown fat reserves. Monitoring temp reg is important. Monitor for hypothermia: - Axillary temp < 97.7 - Cyanosis - ^ RR Core temp varies within newborns but it should be kept at approx 97.7-98.6

Diapering

To avoid diaper rash, newborn's diaper area should be kept clean & dry. Diapers should be changed frequently & peri area cleaned with warm water or wipes & dried thoroughly to prevent skin breakdown. Provide instructions regarding peri cleansing of vulva, or for circumcised or uncircumcised penis

HTT - Abdomen

Umbilical cord should be odorless & exhibit no inestinal structures Abdomen should be round, dome-shaped, and nondistended Bowel sounds should be present within a few mins following birth

Newborn Infection, Sepsis - Client Education

Understand & adhere to infecton control. - Use clean bottles & nipples for each feeding. - Discard unused formula - Perform proper hand hygiene Promote adequate rest for nb , & decrease physical stimulation

Car Seat Safety

Use approved rear-facing car seat in back seat, preferably in middle (away from air bags & side impact), to transport newborn Keep infants in rear-facing car seats until age 2 or until child reaches max height & weight for seat

Erythromycin - Nursing actions

Use single-dose unit to avoid cross-contamination Apply 1- to 2-cm ribbon of ointment to lower conjunctival sac of each eye, starting from inner canthus & moving outward Possible SE in chemical conjunctivitis, causing redness, swelling, drainage, & temporarily blurred vision for 24-48 H. Reassure parents this will resolve on its own. Application can be delayed for 1h after birth to facilitate baby-friendly activities during first period of newborn reactivity.

Bulb syringe

Used for suctioning excess mucuous from mouth & nose

Stethoscope with pediatric head

Used to evaluate HR, breath sounds, bowel sounds

Axillary thermometer

Used to monitor temp & prevent hypothermia Rectal temps avoided because can injure delicate rectal mucosa; an initial rectal temp can be obtained to eval for anal abnormalities

Client education - Breastfeeding

Uterine cramps normal during bf resulting from oxytocin, & promote uterine involution When nb latched on correctly, nose, cheeks & chin will be touching breast. Hunger cues include hand to mouth, or hand to hand movements, sucking motions, & rooting reflex Nbs will nurse on demand after pattern established Bf at least 15-20min per breast to ensure nb receives adequate fat & protein, which is richest in breast milk as it empties breast Nbs need to be breastfed at least 8-12x per 24h Observe for indications that nb has completed feeding (slowing suckling, softened breast, sleeping) Offer both breasts to ensure each breast receive equal stimulation & emptying Burp nb when alternating breasts. Should be burped either over shoulder or in upright position with chin supported. Gently pat back to elicit burp. Begin next feeding with breast you stopped feeding with previous time NB receiving adequate feeding if gaining weight, voiding 6-8 diapers/day, & content between feedings Loose, pale &/or yellow stools are normal during bf

NSW - Meds - Client Education

Utilize drug and/or alcohol treatment center Understand importance of SIDS prevention activities due to ^ rate in nb's of parents who use methadone

Physical Assessment

Vitals should be checked on admission/birth & then: - Q30min x 2 - Q1H x 2 - Q8H Weight should be checked daily at same time using same scale Inspect umbilical cord. Observe for bleeding from cord & ensure it is clamped securely to prevent hemorrhage. In first 6-8 H of life as body systems stabilize & pass through periods of adjustment, observe for period of reactivity: - First period of reactivity - Period of relative inactivity - Second period of reactivity Using facility's preffered pain assmt tool, conduct pain assmt on newborn with routine asmts & following painful procedures

Physiological responses to pain

Vitals: Rapid or shallow respirations; decreased O2 sat; increased HR & BP Skin: Palor or flushing; palmar or general diaphoresis Lab findings: Hyperglycemia, decreased pH, increaed blood corticosteroid levels Other: Increased muscle tone, decreased vagal nerve tone, increased intracranial pressure, dilated pupils

Postmature Infant - Physical Assessment Findings

Wasted appearance, thin with loose skin, having lost some of sc fat peeling, cracked, & dry skin; leathery from decreased protection of vernix & amniotic fluid Long, thin body Meconium staining on fingernails & umbilical cord Hair & Nails can be long Alertness similar to 2-week-old newborn Difficulty establishing respirations secondary to meconium aspration Hypoglycemia due to insufficient stores of glycogen Clinical findings of cold stress Neuro manifestations that become apparent with the development of fine motor skills Macrosomia

LGA Physical Assessment Findings

Weight above 90th percentile Large head Plump & full-faced (cushingoid appearance) from ^ subcut fat Manifestation of hypoxia incl tachypnea, retractions, cyanosis, nasal flaring, grunting Birth trauma (fractures, shoulder dystocia, intracranial hemorrhage, CNS injury ) Sluggishness, hypotonic muscles, hypoactivity Tremors from hypocalcemia Hypoglycemia Resp distress from immature lungs or meconium aspiration Findings of & intracranial pressure: dilated pupils, vomiting, bulging fontanels high-pitched cry.

LGA

Weight above 90th prcentile or >8.8lb LGA can be preterm, postmature, or full term Risk for birth injuries (shoulder dystocia, clavicle fracture or c-sec, asphyxia, hypoglycemia, polycythemia and Erb-Duchenne paralysis due to birth trauma) Uncontrolled hyperglycemia during preg (leading risk factor for LGA) can lead to congenital defects with most common being congenital heart defects, tracheoesophageal fistula (TEF), & CNS anomalies

SGA - Phys Assessment Findings

Weight below 10th percentile Normal skull, but reduced body dimensions Hair sparse on scalp Wide skull sutures from inadequate bone growth Dry loose skin Decreased SC fat Decreased muscle mass, particularly over cheeks & buttocks Thin dry, yellow & dull umbilical cord rather than gray, glistening, moist Drawn abdomen rather than well-rounded Resp distress & hypoxia Hypotonia Evidence of meconium aspiration Hypoglycemia Acrocyanosis

Appropriate for Gestational Age (AGA)

Weight between 10th & 90th percentile

Large for Gestational Age (LGA)

Weight greater than 90th percentile

Small for Gestational Age (SGA)

Weight less than 10th percentile

Low Birth Weight (LBW)

Weight of 2,500 g (5.5lb) or less at birth

HTT - Ears

When examining placement of ears, draw imaginary line through inner to outer canthus of eye. Line should be even with top notch of ear, where ear meets scalp. Ears that are low-set can indicate chromosome abnormality such as Down Syndrome, or kidney disorder Cartilage should be firm & well formed. Lack of cartilage indicates prematurity. Newborn should respond to voices & other sounds Inspect ears for skin tags

HTT - Tonic neck reflex (fencer position)

With newborn in supine, neutral position, examiner turns newborn's head quickly to one side. Newborn's arm & leg on that side extend and opposing arm & leg flex. Seen at birth to 3 or 4 months

Nutrition - Tracheosophageal Atresia

Withhold feeding until esophageal patency determined Elevate head of nb's crib to prevent gastric juice reflux Supervise first feeding to observe for this anomaly

Nutrition - Duodenal Atresia

Withhold feedings until surgical repair is done & nb has begun to pass stools Admin IV fluids as prescribed Monitor for jaundice

When is more extensive physical exam performed?

Within 24H of birth Vitals obtained. HTT assessment performed. Neuro & behavioral assessment s completed by eliciting reflexes & observing responses. Lab data is monitored

Clean gloves

Worn for all physical assessments until discharge.

Hyperbilirubinemia - Physical Assessment Findings

Yellowish tint to sclera, skin, & mucous membranes To verify jaundice, press nb skin on cheek or abdomen lightly with one finger. Then release pressure & observe nb skin color for yellowish tint as skin blanched. Note time of jaundice onset Assess underlying cause by reviewing maternal, prenatal, family, & newborn history Hypoxia, hypothermia, hypoglycemia, & metabolic acidosis can occur as result of hyperbilirubinemia & can ^ risk of brain damage

NSW - Medications

based on withdrawal manifestations Morphine sulphate: Opioid Phenobarbitol: Anticonvulsant Intended effect: Decrease CNS irritability & control seizures for nb with alcohol or opioid withdrawal syndrome

Cord care

before discharge, cord clamp removed. Prevent cord infection by keeping cord dry & keep top of diaper folded underneath it. Client education: - Sponge baths given until cord falls off which occurs 10-14 day after birth. Tub bathing & submersion can follow. - Cord infection (complication of improper cord care) can result if cord not kept clean & dry - Monitor for manifestations of a cord that is moist, red, has foul odor, or has purulent drainage - Notify provider immediatly if findings of cord infection present